PURPOSE: Alternatives to axillary lymph node dissection (ALND) are being developed amid controversy surrounding the therapeutic benefit and overall utility of this routine surgical procedure. Although potential negative side effects associated with ALND are known, we set out to examine whether these side effects contribute significantly to patient reports of quality of life and mental health. PATIENTS AND METHODS: We surveyed 222 women who had received an ALND as part of breast cancer surgery. All women underwent a physical therapy assessment of range of arm/shoulder motion and completed the Modified Post-operative Pain Questionnaire, the Pain Disability Index, the McGill Pain Questionnaire (short form), the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, and the Mental Health Inventory. RESULTS: Seventy-two percent of the women experienced arm/shoulder pain, weakness, or numbness in the week before the interview, and range of motion of the affected arm/shoulder w...

Physical and Psychological Morbidity After Axillary Lymph Node Dissection for Breast Cancer

Formation of a seroma most frequently occurs after mastectomy and axillary surgery. Prolonged drainage is troublesome as it increases the risk for infection and can significantly delay adjuvant therapy. Seroma has been defined as serous fluid collection under the skin flaps or in the axillary dead space following mastectomy and/or axillary dissection. Because the true etiology of a seroma is unknown, a multifactorial-causation hypothesis has been accepted. Surgical factors include technique, extent of dissection and the surgical devices used for dissection. Obliteration of dead space with various flap fixation techniques, use of sclerosants, fibrin glue and sealants, octreotide, and pressure garments have been attempted with conflicting results and none have been consistent. Early movement of the shoulder during the postoperative period may increase the formation of seroma, although delayed physiotherapy decreases the formation of seroma. A detailed analysis of the use of drains showed that use of single or multiple drains, early or late removal, and drains with or without suction are not significantly different for the incidence of seroma. Although there is evidence for reduced seroma formation after early drain removal, very early removal within 24 hours seems to increase formation of seroma. No patient or tumor factors seem to affect seroma formation except body mass index and body weight. Consensus is lacking among studies/trials with different groups producing conflicting evidence. Besides a few established factors such as body mass index, the use of electrocautery for dissection, early drain removal, low vacuum drains, obliteration of dead space, and delayed shoulder physiotherapy, most of the hypothesized causes have not been demonstrated consistently. Thus, seroma remains a threat to both the patient and surgeon. Recurrent transcutaneous aspiration remains the only successful management.

/pdf/seroma-formation-after-breast-cancer-surgery-what-we-have-22y5v25vm7.pdf

Seroma Formation after Breast Cancer Surgery: What We Have Learned in the Last Two Decades

Background: Seroma is a common problem following breast cancer surgery causing patient discomfort and prolongation of hospital stay. Methods: This manuscript reviews the relevant literature obtained by an extensive search of the medline database. In addition papers were also derived from the reference lists of retrieved articles. Results and conclusion: The advantages and disadvantages of the various methods to deal with seroma are discussed. Based on this an individual patient based policy can be formulated.

Seroma following breast cancer surgery

Background The most common complication after breast cancer surgery is seroma formation. It is a source of significant morbidity and discomfort. Many articles have been published describing risk factors and preventive measures. The aim of this paper is to provide a systematic review of studies and reports on risk factors and preventive measures. Surgery lies at the core of seroma formation; therefore focus will be placed on surgical ways of reducing seroma. Methods A computer assisted medline search was carried out, followed by manual retrieval of relevant articles found in the reference listings of original articles. Results 136 relevant articles were reviewed. Though the level of evidence remain varied several factors, type of dissection, tools with which dissection is carried out, reduction of dead space, suction drainage, use of fibrin glue and octreotide usage, have been found to correlate with seroma formation and have been shown to significantly reduce seroma rates. Conclusion Seroma formation after breast cancer surgery cannot be avoided at present. There are however several methods to minimize seroma and associated morbidity. Future research should be directed towards the best ways of reducing seroma by combining proven methods.

/pdf/prevention-of-seroma-formation-after-axillary-dissection-in-49g1pu2irt.pdf

Prevention of seroma formation after axillary dissection in breast cancer: A systematic review

Seromas are the most frequent complications following breast surgery, resulting in significant discomfort and morbidity with possible delays in commencing adjuvant therapies. Varied clinical practices exist in the techniques employed to prevent and manage seromata. This article assesses published literature on the techniques employed in prevention of seroma formation following breast surgery, evaluating the different methodologies used. Although prevention is the best strategy, seromata remain problematic and we consider their management. The principle findings were that prevention is key to the management of seromata. Methods employed to prevent seromata include suction drainage, shoulder immobilization, quilting sutures, fibrin sealants and innovative measures of managing the axilla, among others. The evidence demonstrated that a combination of quilting and drains significantly reduces the incidence and volumes of seromata. These effects are sustained by minimizing use of electrocautery, alongside increasing frequencies of axillary sentinel lymph node biopsies and node sampling. The efficacy data on fibrin sealants is inconclusive and consequently should not be routinely used alone or accompanied by quilting sutures. Clinically significant seromas deemed 'symptomatic' by patients and complicating infected seromas should be aspirated. There are limited data on the recommended treatment of established seromas with a paucity of high-quality studies and further research involving randomized trials are indicated.

Techniques in the prevention and management of seromas after breast surgery

A randomized prospective study was carried out on 53 consecutive female breast cancer cases hospitalized at the Centre Rene Gauducheau, In Nantes (France), with the intent of investigating whether surgical wadding of the axillary fossa with the use of proximate muscular tissue can prevent lymphocele from occurring, and avoid placement of suction drains usually required in conservative management of breast cancer. Results have been significant regarding the incidence of lymphocele (p less than 0.001), as well as the mean puncture volume and the total number of punctures needed (p less than 0.001), thus reflecting the efficacy of a simple method, which yields satisfactory cosmetic results. Failures with this method were related to the technical procedure per se, and not to its principle. The lapse of time required before additional treatment was initiated as subject to a factor not related to the method, but depended upon the recovery of normal shoulder mobilization.

Wadding of the Axilla in the Conservative Treatment of Cancer of the Breast. Prevention of Lymphocele

Axillary lymph node dissection, which is now mandatory in the conservative breast cancer surgery and classically involves Berg's two lower levels, is burdened with numerous complications. In 1988 and 1989, two technical modifications were introduced and are described here: padding of the axilla as preventive treatment of postoperative lymphocele and, more recently, functional axillary lymphadenectomy (FAL) in which the medial cutaneous nerve of the arm, the two perforating intercostal nerves and above all the lateral thoracic pedicle (external mammary artery and vein) are spared. These two technical innovations, more respectful of anatomy, are aimed at reducing the morbidity of conservative breast cancer at a time when detection enables breast cancers to be treated at an increasingly early stage, which results in a increase of negative axillary dissections. The postoperative period is simplified (no drainage, immediate mobilization), and the hospital stay is reduced to 2 days. Complementary treatments can thus be started early on, without any functional or cosmetic damage while the number of lymph nodes removes remains the same as in the conventional axillary dissection technique. The authors describe the operative procedures and analyse the 100 cases of conservative breast cancer they have treated with padding and FAL. These two technical modifications are now systematically used by them in the management of breast cancers.

[A new approach to the axilla: functional axillary lymphadenectomy and padding].

Le capitonnage du creux axillaire dans le traitement conservateur du cancer du sein.

Breast reconstruction with an inferior transversal abdominal flap provides good quality cosmetic results. Indications for this flap technique are presently limited because of the frequency of complications in early series. The aim of this study was to evaluate the different parameters which could reduce the number of complications. From January 1989 to July 1991, 25 patients were treated with this method at the Rene-Gauducheau Centre. All patients were treated with the same surgical technique. Based on the complications observed in this series and a review of the literature, we were able to determine those factors which could limit the number of complications. Preoperative patient selection defined a population at risk of vascular complications. This population corresponded to a good indication for double pediculated flaps. Global flap removal, the muscle and the anterior sheath of the aponevrose together, and maintaining the patient in a sitting position for five days after the operation helped reduce the frequency of complications. Folding the abdominal wall with a nonabsorbable sheath appeared to be a simple and reliable method of reducing the number of abdominal complications. The double pediculated flap was indicated in all cases at risk of partial necrosis or when a large volume was necessary to avoid asymmetry. Using this type of management, breast reconstruction with inferior transversal abdominal flap is the first intention technique used at the Rene-Gauducheau Centre in Nantes.

Breast reconstruction with inferior transverse abdominal flap after mastectomy for cancer

Le capitonnage du creux axillaire dans le traitement conservateur du cancer du sein: prévention de la lymphocèle

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